406552_Well Construction - GW1_20120711

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-B
1. WELL CONTRACTOR:
William Kicker
Well Contractor (Individual) Name
Mad Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-12
3. WELL USE (Check One Box) Monitoring [i Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wriahtsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley Flat ❑ Ridge ❑ Other
LATITUDE 34 ° 12 713.0000 )U
DMS OR 3X.XXXUCXXX DD
LONGITUDE 77 51 ' 987.0000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: WiPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Former Scotchman #182
Facility Name Facility ID# (if applicable)
5200 Wrightsville Ave
Street Address
Wilmington IIC 28403
City or Town State Zip Code
Bryan Lievre
Contact Name
P.O. Box 12055
Mailing Address
Wilmington • NC 28405
City or Town State Zip Code
( 910,6 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL?
YES p NO q%
c. WATER LEVEL. Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
• Top 18'
Top
Top
: 11. DRILLING LOG
• Top Bottom
•
•
0 / 25'
r,: r-
... �y.. r�•.sa
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
•
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NJA METHOD OF TEST
: f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING:
Top 0
Top Bottom Ft.
Top Bottom Ft.
Depth
Thickness/
Diameter Weight Material
Bottom 20' Ft. 2"
8. GROUT:
Top 0
' Top 15'
Top
9. SCREEN:
Depth Material
Bottom 15' Ft. Portland
Bottom 18' Ft. Bentonite
Bottom
Depth
Top 20' Bottom 25'
Top___ Bottom
Top Bottom
: 10. SAND/GRAVEL PACK:
Depth
Bottom
Ft.
Sch40 PVC
Method
Trimmie
Pour
Diameter Slot Size Material
Ft. 2" in. .010 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
25' Ft. #2 Silica
Bottom Ft.
Bottom Ft.
/
/
/
/
12. REMARKS:
Formation Description
Silty Sand
p, l..i `l 0:s1
'P
t._
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED TO .' ELL OWN R.
/%404
• PRINTED NAME OF PERSON CONST U
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone [phone]
ING THE WELL
Form GW-1 b
Rev. 2/09